Provider Demographics
NPI:1902988272
Name:DIEM Q. PHAM, D.O., INC.
Entity Type:Organization
Organization Name:DIEM Q. PHAM, D.O., INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:DIEM
Authorized Official - Middle Name:QUYNH
Authorized Official - Last Name:PHAM
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:909-392-3230
Mailing Address - Street 1:2740 N GAREY AVE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:POMONA
Mailing Address - State:CA
Mailing Address - Zip Code:91767-1800
Mailing Address - Country:US
Mailing Address - Phone:909-392-3230
Mailing Address - Fax:909-392-3224
Practice Address - Street 1:2740 N GAREY AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:POMONA
Practice Address - State:CA
Practice Address - Zip Code:91767-1800
Practice Address - Country:US
Practice Address - Phone:909-392-3230
Practice Address - Fax:909-392-3224
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-19
Last Update Date:2008-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A7309207NS0135X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural DermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW20222Medicare ID - Type Unspecified